2000_0114 J c WATER
Issued / �/ Finished Employee, %��A '-. Grid map
Nemec 6a,,, , (Le -a--- Address: _z ' �hf��0`� li�
?hone Number: (NM): (WX):
Time for water locate
Check for: Accuracy wt:_ Mawr Lsakc Clack water present: Initial weer relocation io.p«sioe Re - tend
1.Backf1ow /nem. 2. Repair 3.Maintenance 4.Other
Backflow Insp. A.Main Line A.Pumps A.Line Locate
B.Valves B.Water Tower B.Inapeetion
Bkflow Cert.Date C.Service Line C.Samples C.Tap
D.Hydrants D.lquipment D.Excavation
Re -Cert. Date E.Safety
5. Reason for failure: A. Electrolysis B. New construction C. Poor inatallatior.
D. Other
6. List of safety equipment at site is applicable:
A. Barricades 3. Ones , C. - g a pe D Light E. Other
Request for Serviceman: /2 /Z2/l,� �f - (
Meter /Service Leak: Classify - City: Customer: .
R. water Loss (Eaimaw:: GPM Fire plug flushing Total Gallons
3.Was Water Metered: Yes No
:.was Customer Notified: Verbally DOORINOCCER
76 a/7 vehicle /Equipment Used
3.1! Meter Change Out: Unit # Miles Firs !quip
;.Old Meter# Readies
g /Ytf // - / v 07 7.0r
3. New Meter # 77. Reading
ef 44 C.Old Meter Sise /'.'1►pe : � ...._D: -New Meter Size /Type X /i
E .Type of work performed or findings: 5d� / / ����� e ,7,2T
9.I` mainline or deep service repair, describe type of pipe or service line and condition:
10.Manhours: , 3 0 , , Crew members: _.
II.List Materials Used:
12. If you had an accident /incident while performing this request. Did you report it? yes or no
13.Water Utilities meter inspection: pass or fail
14_Acw many trios to do task?